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Speech by Andy Burnham MP, Secretary of State for Health, 4 November 2009, at the Urban Institute, Washington DC: The politics of health reform

It’s a pleasure to be here this morning. I want to thank the Urban Institute for hosting this event, Robert [Reischauer] for that kind introduction, and all of you for giving your time to be here.

I thought it might help if I began by making one thing clear at the start: you are not about to hear another intervention into the healthcare debate here in the US.  From what I can tell, you seem to have more than enough people queuing up to do that already, and you don’t need another.

Healthcare is a complicated business and there is no right or wrong way to do it, as illustrated by the fact that no two healthcare systems on earth are the same. Each is the product of its people, culture and history – and its reform is properly the preserve of domestic political debate.

But, what I thought I could usefully do during this visit to Washington for the Commonwealth Fund Annual Symposium is to offer some of perspectives on a decade of health reform in England, at times a hard road, with many ups and downs along the way, and always the subject of an intense political debate.

We have an interesting story to share, but the motto of that story is that, for all the political challenges it has thrown up, it has been well worth sticking the course.

Secondly, and more importantly, I wanted to look ahead and talk about my plans for the NHS in the next decade, as we look to deal with the same pressures faced by all health systems in the G20. I am sure I am not the only Health Minister in the world facing a hard job to persuade my colleagues in the Treasury to dig deep for health as the after-effects of the economic downturn on public spending are felt. At the same time, the pressures are stacking up - from the immediate challenge of pandemic influenza to the longer-term ones of an ageing society, obesity and lifestyle diseases.

It’s a tough outlook, but all health systems in the world will have to continue to reform or risk slipping back. I want to take it head on and later this year will lay out a route-map for the NHS 2010 to 2015, building on the foundations we have laid. It won’t be a recipe for standing still but for helping the NHS make further progress. But getting there is a very different challenge to the one that faced us 10 years ago. If it is to happen, it will require us to adapt our approach to reform for new times, learning from the last decade. It will mean spending less in hospitals and more closer to the patient’s home. It will mean changes to services on a scale not seen before in its 61-year history, which will raise another difficult public debate.

So those are the two key issues I wanted to address and, along the way, I hope I might get the chance to offer a few gentle corrections to the misapprehensions about the NHS that have crept in the public debate here. As you might have picked up, we’re quite proud of it. With my colleagues, we would be very pleased to take any questions at the end.

So, first some reflections on reform.

It seems to me that the issue at the heart of the debate here in the US has a clear parallel to the one that confronted the incoming Labour Government in Britain in 1997. Back then, millions of British people did not have acceptable access to health care. But in our case they were not a minority of the population; the scourge of waiting and waiting lists affected everyone. People could wait months on end for routine treatments, over a year for a heart bypass operation, or a whole day in Accident and Emergency Departments.

Waiting lists were a product of managing demand in a malnourished system, with too few staff and poor buildings. A further symptom of inadequate funding that outraged the public was the emergence of ‘postcode prescribing’. As local health trusts looked to manage spending pressures, they took different decisions about new drugs and treatments. But, in a national system such as ours, the result was inexplicable to the public – how could people with the same clinical condition living in the same street be offered different standards of care?

So, the call to the new Government was to place order on a struggling system.

Our response was an aggressive programme of investment and reform that got underway in earnest at the start of this decade. It is important to stress the two sides of this approach – investment and reform - because it was never a case of simply throwing money at an unreformed service, as some on the Right sought to claim. We were determined to ensure that with money would come serious change to the way the NHS operates, and specifically changes that would make it more accountable to the public that paid for it.

For all its great strengths, the NHS at its worst has a like-it-or-lump-it feel – as perhaps might be common in any service free at the point of use. It can put institutional convenience ahead of the convenience of the individual.

So national waiting targets were introduced for A&E, planned procedures and suspected cancers. Targets have been much-maligned and held responsible for a range of ills, but they were essentially an expression to the system of what mattered to the public and the minimum standard that everybody should be able to expect. In essence, they held the system to account and represented a shift of power from professionals to patients. And the creation of the National Institute for Health and Clinical Excellence – or NICE – further enhanced accountability in the system by making clear judgement on the treatments and technologies that should be available to everyone.

And these changes have produced real results: today, lengthy waiting times are a thing of the past and nobody is denied the care that they need. As the waiting lists began to disappear, we were able to empower the patient further by introducing choice of hospitals, and we continue to push that deeper into the NHS today.

But it has not been without costs. Placing order on a failing system must be managed top down. Targets drove the system hard and were the right thing to do. But we have come to learn that the top-down approach can only take you so far. It is not a great way to win the hearts and minds of the people who must make it all work. Looking back, I can see now how the emphasis on targets began to imply a lack of trust in staff at the front line that become disempowering.

So we have learned to adapt our approach from reform. To coincide with the 60th anniversary of the NHS in 2008, Lord Darzi was asked by the Prime Minister to conduct a Next Stage Review of the NHS. It was a hugely important process in healing the fractures that had arisen from a decade of reform and re-uniting people around the central goal of improving quality and the patient experience. At its heart is the simple recognition that effective clinical leadership is crucial in securing successful health service change. It lays the ground for the challenges we are about to face as we change local services for the new era.

Looking back, I think all my predecessors would agree that turning round a health system was a bigger and tougher job than we thought. Change in health is hard and raises anxieties among public, patients and staff. It created political pressures, predictably with the Right but also on the Left. For many in the Labour Movement, the NHS is sacred and changing it is hard-fought. But, because we did, and because it is now delivering for the public, it is our strongest card as a Government as we head into the coming General Election. We hope that tomorrow’s Commonwealth Fund report will provide independent endorsement of our contention that a decade of reform under the Labour Government has improved health and saved lives.

What about the next decade in the NHS?

I have said many times that I don’t want to overclaim for the NHS. In the last decade, it has gone from poor to good. Building on this solid foundation, our mission in the next decade is to take the NHS from good to great. For me, that means two things: making the NHS more preventative and more people-centred.

With that in mind, I am here to learn from your system. At its best, it leads the world in preventative care. We’ve already learned a lot from you – for example on publishing data on patient outcomes to drive up quality, and are now looking at how we can improve early diagnosis of cancer drawing on the best of the US system in giving people immediate access to crucial tests. We look to centres like Mayo Clinic or Johns Hopkins in this regard and I saw for myself yesterday in Baltimore how the expertise of the hospital can be brought into the community.

Going forward, I want our best Foundation Trusts to work in a similar way – taking services and staff out of hospital to the patient, detecting disease early and preventing ill health. In this way, I think we can align the drive to be more efficient and productive with being more people-centred and preventative. Later this year, we will bring forward changes to the financial system to make sure the money flows support those trends rather than work against them. Under any scenario, it means spending a smaller percentage of the cake in hospitals. Increasingly clinicians are being judged against their patients’ clinical outcomes and satisfaction – and under the Quality and Outcomes Framework, they are paid according to their performance. Now we want to start expanding this approach to other parts of the service, and start to link payment to quality rather than just activity.

In short, we want to take the best of the US system make it available to everyone.

But, alongside improved care, we must put greater emphasis on prevention in its widest possible sense.

Secretary Sebelius points out that: ‘85 percent of the money spent on health care [in the US] goes toward people with at least one chronic condition. Some of these conditions include diabetes, heart disease and obesity – conditions that we know we can prevent.’ In England this figure is around 70 percent, and it’s expected to rise.

When the founder father of the NHS, the great Nye Bevan, introduced his National Health Service Bill to the House of Commons in 1948, he said that the system he was creating would be so good at preventing ill health that it would cost less and less every year. 61 years on and with a £100 billion budget, some might be tempted to say, our Chancellor Alistair Darling for instance, that this noble vision hasn’t quite come off.

The NHS has been too much of a pick-up-the-pieces system and hasn’t been good at intervening early. We need to move away from the old diagnose-and-treat approach towards a new predict-and-prevent approach. We’ve got to get beyond being passive and waiting for ill people to enter the system. Treating people in hospital is not a sign of success, but often of some failure that has brought them there in the first place.

Obesity is a classic case in point. The UK, like the US, is in the grip of a serious, and potentially devastating obesity epidemic. Our leading scientists predict that unless we take radical action as a society to change our lifestyles, four-fifths of all British people could be overweight or obese by 2050. The associated disease burden – an overwhelming tide of diabetes, heart disease and cancer – could bankrupt the NHS at a stroke.

We received positive news yesterday that obesity in children may be levelling off for the first time since the 1970s. But there can be no room for complacency.

Getting people active is an essential part of preventing ill-health. The NHS spends nearly two billion pounds a year – more than £3,000 a minute – on treating conditions that could be prevented by regular exercise. Yet, the UK currently languishes near the bottom of the European physical activity tables. I’ve set an ambitious goal of putting us in the top four by the time we host the Olympics in 2012. We need a big cultural change in our health service so that promoting physical activity moves from the periphery to the mainstream – it should be integral to 21st century health care.

I know that you are taking this problem seriously here in the US – putting a greater emphasis on upfront investment, providing upstream, pre-emptive solutions such as lifestyle nursing to tackle these problems before they develop. These sort of proactive steps can save money, and moreover they can change people’s lives.

We’ve also responded with a push on public information. Change4Life is a unique grassroots programme bringing in everyone from the local convenience store to the new Wii Fit Plus game, from the Simpsons to multinationals like PepsiCo. They’re all involved in different campaigns and activities under one brand with the aim of getting people doing more exercise, eating better and leading healthier lives. Swim4Life, for instance, is a campaign to provide free swimming in public swimming pools for under-16s and over-60s – so far, children have taken advantage of seven million free swims. 

Change4Life recognises that obesity is a community issue – about how people live their lives, about their habits, their culture, their opportunities to stay healthy. As a result, it demands a collective, local response. But obesity is also global. It reflects a prevailing shift in lifestyles and tastes across all affluent, industrialised societies – and it’s therefore a challenge we should be fighting together.

Alongside obesity, we face the demographic challenge and the ageing society. President Obama argues that reforming healthcare in the US is an economic necessity. Surely that will become more and more true as this century progresses.

By 2033, it is predicted that the number of people in the UK aged 85 will rise from 1.3 million to 3.3 million, while the ratio of working age adults to pensioners – the so-called dependency ratio – will drop below three for the very first time in 20 years time. Improvements in medical treatments are also extending the lives of those with disabilities or long-term conditions.

In the UK, we’re making the same case about the economic necessity of reform on long-term care, or social care. We need to change our approach – to provide better care, but also to keep people in work longer, help them get back into work more quickly, and help people who are providing care to stay economically active.

We’re asking a fundamental question about our priorities as a society, how we share the costs and risks of the quality care that we all aspire to give our older and disabled people. This is likely to give rise to the same intense public debate you’re having here in the US.

If we were designing the UK’s welfare state today, long-term care would be at the centre, not at the margins. So we’re committed to establishing a National Care Service, to work alongside the National Health Service. This is a major reform – it’s a chance to re-imagine social care from first principles, to reposition care and support at the very heart of social policy and the very heart of our society’s future, to integrate the long-term care of older people in their homes, with the health care provided through hospitals and community provision. It is this integration – which organisations like the Veterans Administration and Kaiser Permanente do so well here in the US – which will realise the benefits of co-ordinating early intervention with the management of long-term conditions to deliver high quality holistic care

Conclusion

In conclusion, the NHS has been through a period of transformation.

Today 93% of people rate the NHS as good or excellent. We are proud of the service it provides. People of all ages – even into their 90s – get the most hi-tech care we can provide. And from 2012, this right to equal care will be a legal entitlement. The NHS Constitution – which will be recognised in law next week – sets out the level of care that patients can expect from the service, the standards that they should demand, and their right to choose their provider from whichever sector they prefer. It cements into allow law all the progress we have made. Health reform in England has been a tough and bumpy road but it’s worth sticking the course as the prize is great.

And I think the NHS model makes us well-placed to face a difficult future. It has two enduring strengths. It is inherently efficient, as people only take out what they need and there is no duplication. Secondly, its underlying values continue to inspire and motivate its staff and speak to the vocation of health professionals.

Because of these strengths and because of the reforms of the last decade the NHS model is now beyond question in the UK. But as I’ve set out today, the ways of working, the priorities of the service and the focus of its resources will continue to shift. Obesity and our ageing population provide the NHS, and our society, with significant challenges. It is imperative that we must move away from the traditional focus on hospitals to invest more resource in communities, closer to people’s lives.

The NHS has endured not despite change, but because of it. After 61 years, the service continues to grow and adapt. I look forward to learning from you in meeting our shared challenges, and beginning the next chapter of change.

Thank you.